HTA Respiratory Conditions Consultation Request Form

HTA Respiratory Conditions Consultation Request Form

Your health story matters. Start by sharing your main question or concern. The more details you provide about your symptoms, history, and current challenges, the better we can support you in understanding and helping you manage your respiratory condition.
What is your question?

Contact Information & Demographics
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender - Required for interpreting normal pulmonary values

MaleFemale
Height and Weight - Required for interpreting normal pulmonary values
Age - Required for interpreting normal pulmonary values

Diagnostics & Tests
Have you been diagnosed with asthma?

YesNoDon't know
If yes, who diagnosed you and what month and year?
Have you had a pulmonary function test?

YesNoDon't know
If yes, when and where?

Hospitalizations & ER Visits
Have you been hospitalized for your asthma?

YesNo
If yes, When and how often
Have you been hospitalized for your asthma?

YesNo
If yes, When and how often

Medications & Treatment
List all your asthma medications, types, dosage, and frequency
Do you use a spacer for your inhalers?

YesNoDon't know

Lifestyle Impact
How many hours in a week do you spend managing your asthma?
In the last 4 weeks, how many days of work/school/fun/exercise did you miss due to asthma?
How much money are you spending per month on MEDICATIONS for your asthma?
How much money are you spending per month on SUPPLIES for your asthma?
Do you feel financially burdened by asthma cost?

YesNoInsurance pays all or part
Do you have the following supplies?

Pulse oximeterSpirometerPeak Flow meterNebulizerSpacer

Satisfaction with Care
Are you satisfied with the way your current healthcare team is helping you manage your asthma?

YesNo
Please explain why or why not satisfied

Important information prior to submitting this form
Our initial evaluation is free and will be emailed to you within 48 hours. This is HTAs way of beginning your journey to better health. Chronic conditions require proactive and continuous monitoring, measuring and managing to achieve better outcomes. We invite you to join us with one of our subscriptions and become a partner in our private HTA Zero Communities where you can interact with other HTA members who also receive clinical information and advice from our trusted clinicians.

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge and is intended for initial consultation purposes only.

This form does not constitute medical advice, diagnosis, or treatment, and does not create a doctor–patient relationship.

Always seek the advice of your physician or other qualified healthcare provider with questions you may have regarding a medical condition.

If you are experiencing a medical emergency, dial 911 immediately.
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